Julie K. Heimbach

Routine preoperative laboratory analyses are unnecessary before elective laparoscopic cholecystectomy.

Background: We formulated a clinical pathway (CP) for elective laparoscopic cholecystectomy (LC), which included the following preoperative evaluation: history and physical (H&P), right upper quadrant ultrasound (US), and liver function tests (LFTs). We hypothesized that routine LFTs did not alter management beyond that dictated by H&P and US, and could be excluded from the CP. Methods: The study involved 387 consecutive patients undergoing elective LC. Abnormalities in the preoperative evaluation were compared with the finding of choledocholithiasis or other unexpected outcomes. Results: In 187 (48%) patients, abnormalities were found by H&P (n = 7), US (n = 13), and LFTs (n = 177). Seven patients (2%) had documented choledocholithiasis; two had abnormal H&P; three had abnormal US; and four had abnormal LFTs. No patient with choledocholithiasis had abnormal LFTs but normal H&P and US. Conclusions: Routine LFTs before elective LC are not cost effective. Before LC H&P and US are warranted, but LFTs do not add any useful information and should not be routinely measured.

Therapeutically accessible clinical cardiac states

A descriptive physiologic state assumes clinical relevance when its mechanism(s) are determined to be therapeutically accessible. During the past several decades, a spectrum of clinical cardiac functional descriptors have gained common use. Healthy, preconditioned, stunned, hibernating, reversibly ischemic, apoptotic, and necrotic are all adjectives used to identify clinically relevant myocardial status. The purposes of this review are: 1) to examine our current terminology of functional cardiac status; 2) to explore the bioenergetic complexion of the cardiomyocyte in these various states; and 3) to identify instances in which the knowledgeable surgeon can influence a patient’s cardiomyocyte function. We postulate that the energy status of the cell determines its clinical condition and that a clinical appreciation of this bioenergetic status can translate into applicable therapeutic strategies. Clinically, perturbations of healthy myocardial energy state are described as preconditioned, stunned, hibernating, apoptotic, and necrotic. Ischemia is a frequent, clinically relevant event resulting from coronary vascular dysfunction. In this review, rigorously delineated clinical definitions will serve as a basis on which to relate mitochondrial bioenergetic function. HEALTHY MYOCARDIUM Mitochondria produce virtually all the energy required for normal cardiac function, constitute onethird of a cardiomyocyte’s volume, and consume

94 – Academic Surgical Mentoring

Surgical training has long been acknowledged as more an apprenticeship than a residency. From generation to generation, knowledge based on experience is passed down. Without this interaction and exchange, the intricacies and joys of medicine could not be transferred and, hence, experienced in their fullest. In sharing their experience and insight, mentors, in particular, have unique opportunities and responsibilities. Sociologists have examined factors by which medical students choose a specialty. Lifestyle, financial rewards, esteem, and parental/societal pressures have been subjected to multivariate analysis. Repeatedly, these obviously influential factors have been comfortably ignored in the decision-making process. Consistently, the most robust determinant of career selection is a mentor with whom the student identifies. Interestingly, the academic progeny need not be a clone of the mentor. Students are now conceptually fluent with the wonders of transgenic technology. Students imaginatively splice the “effect” of a socially responsible and rewarding surgical practice with the “affect” of an encouraging, engaging elementary school teacher. Mentors are mosaics. With the evident exception of the authors of this paper, mentors are rarely perfect—even Mary Poppins could not deal with an aortic dissection. Fortunately, a medical school faculty—and society in general—is an a la carte menu.